Not just a hernia: Symptoms disguise life-threatening condition

The motto for the City of Barron, Wisconsin, is: "Be kind. Be strong. Be together. Be Barron." Nathan Emmons has embraced this motto in all that he does.

Over the span of 44 years, he has focused on bringing people together and caring for the community. He is a 17-year veteran of the Barron Police Department and founded the city's K9 program. Before that, he was a pastor for 27 years, counseling families during times of joy and crisis.

While he was focusing on the community's heart, his own heart was hiding a secret, life-threatening condition.

Concerning symptoms

In 2016, Nathan was working a night shift at the police department when he began experiencing chest pain. An otherwise healthy person, he was alarmed and went to the Emergency Department at Mayo Clinic Health System in Barron. The results from an echocardiogram and blood work were normal, and he was sent home to recover.

Nathan continued to have sporadic periods of chest pain, nausea and vomiting after periods of physical exertion.

"I would have chest pain and puking, but then it would be fine," he says. "I found that if I drank water, it would relieve my symptoms. So I just carried water with me all the time."

Hernia discovery

While he was controlling most of his symptoms, Nathan really wanted to get to the root of the problem. In 2019, Brad Kruger, a Family Medicine physician assistant and Nathan's primary care provider, referred him to Gastroenterology for additional testing.

An endoscopy showed that Nathan had a hiatal hernia. This occurs when the upper part of the stomach budges through the large muscle separating the abdomen and chest.

"Hiatal hernias are common in Western countries. The frequency of hiatal hernias increases with age from 10% in patients younger than 40 to 70% in patients older than 70 years. However, only 9% have symptoms," says Christian Mendez, M.D., a gastroenterologist at Mayo Clinic Health System in Barron and Eau Claire, Wisconsin. "Large hiatal hernia can cause heartburn, regurgitation of food or liquids into the mouth, difficulty swallowing, chest or abdominal discomfort, and early satiety."

Over time, Nathan's symptoms became more regular, and drinking water no longer provided relief.

"By the end of 2021, it was taking less effort to cause symptoms," he says. "Even brushing snow off the car or running the K9 dog around cars for drug sniffs triggered chest pain and vomiting," Nathan says. "I always had to carry a bottle of water with me."

In January, Nathan decided to have Dr. Mendez reevaluate his hernia. After a repeat endoscopy, Dr. Mendez confirmed that Nathan had a small hiatal hernia and inflammation of the stomach lining.

Failing stress test

These conditions explained Nathan's nausea and vomiting but not his chest pain. Dr. Mendez wanted to dig deeper.

"As the upper endoscopy findings didn't explain his symptoms, I asked him about risks factors for heart disease, such as cholesterol, tobacco use and family history of cardiac disease. His family history of coronary artery disease was positive in several relatives," says Dr. Mendez. "I immediately thought about an atypical presentation of coronary artery disease and recommended a stress test."

While not excited about another test, Nathan was happy that Dr. Mendez focused on more than just his gastrointestinal symptoms.

"He had a genuine interest in me as a person. He asked questions about the location of my pain, to describe it and my overall health history," says Nathan. "He took the time and thought outside of the box. At least outside of his specialty."

On April 14, he traveled to Mayo Clinic Health System in Eau Claire for an exercise stress test that would show how his heart was working during physical activity.

"I wasn't worried because, in my mind, I was dealing with a hernia — not a heart problem," recalls Nathan. "But then I had a lot of pain during the stress test. I would score the pain higher than a 10, if possible. I failed it miserably."

After the test, Joel Beachey, M.D., a Mayo Clinic Health System cardiologist, explained the results to Nathan and recommended immediate treatment.

"His stress test was markedly positive for ischemic changes, or findings that suggest decreased blood flow to the heart," says Dr. Beachey. "When he exercised, he developed regional wall motion abnormalities, meaning that parts of his heart were not squeezing effectively. His ejection fraction — a marker of heart-pumping function — also decreased. This is a concerning warning sign of a significant blockage, usually in an important artery like the left main or left anterior descending coronary artery."

He also explained that previous echocardiogram tests results appeared normal because they were completed while Nathan was at rest.

"If arteries are not completely blocked, patients may be getting normal blood flow during times when they are not active," says Dr. Beachey. "Thus, the ischemic changes we look for on an echocardiogram may not be present."

Treatment for blocked arteries

Dr. Beachey recommended that Nathan have a coronary angiogram right away and not wait until after the Easter holiday weekend. This procedure uses X-ray imaging to see if the heart's blood vessels are restricted.

"In meeting with him and reviewing his history, I became concerned that his symptoms were becoming more unstable. He was describing rapid recent progression of symptoms with significant limitations with decreasing amounts of activity," he says. "While he had been having symptoms for months, the progression concerned me about his risk for an acute coronary syndrome event soon. I recommended that we proceed with coronary angiogram, and, thankfully, we were able to arrange for an angiogram the following day."

On April 15, Nathan's wife lined up someone else to play the organ during Good Friday church service so she could drive him to Eau Claire for the coronary angiogram. Mayo Clinic Health System cardiologist D. Fearghas O'Cochlain, M.D., injected dye into Nathan's vessels and discovered the source of his discomfort: significant blockages in four major arteries of his heart.

"The angiogram showed that Mr. Emmons had severe coronary artery disease involving multiple vessels," says Dr. O'Cochlain. "He had 90% blockages in the proximal and midleft anterior descending arteries, plus left circumflex artery. Mr. Emmons also had a 70% blockage of his first diagonal artery."

Dr. O'Cochlain placed four stents in the narrowed arteries to increase blood flow around Nathan's heart. This included a stent in the left anterior descending artery, sometimes called the "widow-maker."

"The left anterior descending artery provides blood supply to a large portion of the left ventricle," explains Dr. Beachey. "Heart attacks involving this artery have the worst prognosis among all types of heart attacks and have the highest rates of sudden death, due to the significant portion of heart muscle that can be involved."

When Nathan woke up in recovery, he learned about the extent of the blockages. He was relieved the care team was able to restore blood flow.

"To say I was shocked would be an understatement," he says. "I eat healthy and take supplements that are good for my heart, so I didn't expect it to be that bad."

Dr. Beachey explains Nathan didn't have any of the typical risk factors for artery blockages like high blood pressure, high cholesterol, smoking or diabetes.

"Mr. Emmons had no specific risk factors, aside from family history. He has been otherwise healthy and active without prior known significant medical issues," says Dr. Beachey. "I suspect his coronary disease is strongly genetically influenced, as he reported a family history of heart attacks."

Dr. O'Cochlain explains that symptoms of heartburn, acid reflux and chest pain overlap due to reduced blood flow to the heart. This can lead some people to downplay symptoms and not seek medical care.

"Many people interpret the symptom 'chest pain' as a sharp localized discomfort similar to a knife. However most do not experience cardiac discomfort in this way," he says. "It's often pressure, burning, poorly localized discomfort or a cramp. Because it is not what they think of as 'pain,' people may either dismiss it or attribute it to something else, such as heartburn."

Welcome visit during recovery

Nathan got another surprise while in the recovery area: a visit from Dr. Mendez.

"I wanted to celebrate with him and his wife," says Dr. Mendez. "I knew he was coming for his cardiac intervention, and I like to follow up with my patients after referring to other specialties."

This gesture meant a lot to the Emmons family.

"He had no other reason to be there, except that he cared," Nathan says. "It meant a lot to me and my wife that he checked in on us. When she realized who he was, she gave him a big hug and told him thank you."

Next steps

After the angiogram and stent placements, Nathan was able to recover at home. Shortly after, he began cardiac rehabilitation to rebuild the strength and stamina of his heart.

Once recovered, he will discuss with Dr. Mendez treatment options for his hiatal hernia. Nathan is hoping to get the green light to spend time golfing and fishing this summer.

Reflecting on the last months, Nathan says he feels blessed to have met Dr. Mendez and to have received expert, timely care from the Cardiology team.

"Had he not recommended the stress test, I don't want to think about what could have happened. Any one of the times that I pushed through the pain before could have easily been my last day," he says. "God kept me here for a reason."